Question

select all that apply

select all of the following that are factors in affecting eligibility for benefits for an hmo patient.

the patient has met the deductible.
the patient is assigned to the pcp as of the date of service.
the provider is a plan participant.
the patient is listed on the plans enrollment master list.
the patient does not have a preexisting condition.

Explanation:

Analyze HMO eligibility requirements

Using the Eligibility Verification Steps and HMO PCP Assignment knowledge points:

• The patient has met the deductible: HMO plans typically do not have deductibles for standard in-network care (or if they do, meeting it does not determine basic eligibility for benefits). Thus, this is not a primary factor for HMO eligibility.
• The patient is assigned to the PCP as of the date of service: HMO plans strictly require patients to be assigned to a Primary Care Physician (PCP) to receive covered benefits. This assignment must be active on the date of service.
• The provider is a plan participant: HMOs require patients to use in-network providers (plan participants) for services to be covered, except in emergencies.
• The patient is listed on the plan's enrollment master list: To be eligible for any benefits, the patient must be actively enrolled and appear on the insurer's master enrollment list.
• The patient does not have a preexisting condition: Under modern healthcare regulations (such as the Affordable Care Act), coverage cannot be denied or affected by preexisting conditions.

Answer:

• The patient has met the deductible.
• The patient is assigned to the PCP as of the date of service. (Correct answer)
• The provider is a plan participant. (Correct answer)
• The patient is listed on the plan's enrollment master list. (Correct answer)
• The patient does not have a preexisting condition.